Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
Department of Intensive Care, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
Blood Purif. 2021;50(3):355-363. doi: 10.1159/000510996. Epub 2020 Oct 26.
Patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 frequently develop severe acute kidney injury (AKI). Although continuous renal replacement therapy is the standard of care for critically ill patients, prolonged intermittent renal replacement therapy (PIRRT) may be a feasible option. We aimed to describe the tolerability and security of PIRRT treatments in COVID-19 patients with ARDS who required mechanical ventilation and developed severe AKI.
We prospectively analyzed patients who underwent PIRRT treatments at a COVID-19 reference hospital in Mexico City. Intradialytic hypotension was defined as a systolic blood pressure decrease of ≥20 mm Hg or an increase of 100% in vasopressor dose.
We identified 136 AKI cases (60.7%) in 224 patients admitted to the intensive care unit. Among them, 21 (15%) underwent PIRRT (130 sessions) due to stage 3 AKI. The median age of the cohort was 49 (range 36-73) years, 17 (81%) were male, 7 (33%) had diabetes, and the median time between symptoms onset and PIRRT initiation was 12 (interquartile range [IQR] 7-14) days. The median of PIRRT procedures for each patient was 5 (IQR 4-9) sessions. In 108 (83%) PIRRT sessions, the total ultrafiltration goal was achieved. In 84 (65%) PIRRT procedures, there was a median increase in norepinephrine dose of +0.031 mcg/kg/min during PIRRT (IQR 0.00 to +0.07). Intradialytic hypotensive events occurred in 56 (43%) procedures. Fifteen (12%) PIRRT treatments were discontinued due to severe hypotension. Vasopressor treatment at PIRRT session onset (OR 6.2, 95% CI 1.4-28.0, p: 0.02) and a pre-PIRRT lactate ≥3.0 mmol/L (OR 4.63, 95% CI 1.3-12.8, p: 0.003) were independently and significantly associated with the risk of hypotension during PIRRT. During follow-up, 11 patients (52%) recovered from AKI and respiratory failure and 9 (43%) died. Several adaptations to our PIRRT protocol during the COVID-19 outbreak are presented.
PIRRT was feasible in the majority of COVID-19 patients with ARDS and severe AKI, despite frequent transitory intradialytic hypotensive episodes. PIRRT may represent an acceptable alternative of renal replacement therapy during the COVID-19 outbreak.
继发于 COVID-19 的急性呼吸窘迫综合征 (ARDS) 患者常发生严重急性肾损伤 (AKI)。虽然连续性肾脏替代疗法是危重症患者的标准治疗方法，但间歇性肾脏替代疗法 (PIRRT) 可能是一种可行的选择。我们旨在描述 COVID-19 患者接受机械通气并发生严重 AKI 后接受 PIRRT 治疗的耐受性和安全性。
我们前瞻性分析了在墨西哥城的一家 COVID-19 参考医院接受 PIRRT 治疗的患者。透析中低血压定义为收缩压下降≥20mmHg 或血管加压药剂量增加 100%。
我们在 224 名入住重症监护病房的患者中发现了 136 例 AKI 病例（60.7%）。其中，21 例（15%）因 AKI 第 3 期接受 PIRRT（130 次）。队列的中位年龄为 49 岁（范围 36-73 岁），17 名（81%）为男性，7 名（33%）患有糖尿病，PIRRT 开始与症状出现之间的中位时间为 12 天（四分位距 [IQR] 7-14 天）。每位患者的 PIRRT 治疗中位数为 5 次（IQR 4-9）。在 108 次（83%）PIRRT 中，达到了总超滤目标。在 84 次（65%）PIRRT 中，在 PIRRT 过程中去甲肾上腺素剂量中位数增加了+0.031 mcg/kg/min（IQR 0.00 至+0.07）。56 次（43%）PIRRT 过程中发生透析中低血压事件。由于严重低血压，15 次（12%）PIRRT 治疗停止。PIRRT 开始时的血管加压药治疗（OR 6.2，95%CI 1.4-28.0，p：0.02）和 PIRRT 前乳酸≥3.0mmol/L（OR 4.63，95%CI 1.3-12.8，p：0.003）与 PIRRT 期间低血压的风险独立且显著相关。在随访期间，11 名患者（52%）从 AKI 和呼吸衰竭中恢复，9 名患者（43%）死亡。在 COVID-19 爆发期间，我们提出了对我们的 PIRRT 方案的几项调整。
尽管经常出现短暂的透析中低血压，但 PIRRT 在大多数继发于 COVID-19 的 ARDS 和严重 AKI 患者中是可行的。在 COVID-19 爆发期间，PIRRT 可能是肾脏替代治疗的一种可接受的替代方案。
